PhilHealth Primary Care Benefit- Assessment of Initial Implementation. Leizel P. Lagrada MD MPH PhD PhilHealth

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1 PhilHealth Primary Care Benefit- Assessment of Initial Implementation Leizel P. Lagrada MD MPH PhD PhilHealth

2 Background Starting 2000, PhilHealth started a out-patient benefits that include TB-DOTS, Maternity Care Package and Out- Patient Benefit for indigent (sponsored) PhilHealth members In 2006, a PhilHealth commissioned study showed that among its SP members: Approximately 30% did not know what health care services were available; another 41% did not know that PhilHealth membership was accepted in health centres 29% of respondents were unable to access the services they needed

3 Moreover, OPB Package Evaluation reports... Accreditation as OPB provider was based on inputs of care, with no relation with services actually provided Extremely low utilization of OPB-related services, ave contacts per member per year Lack of awareness may have contributed to low benefit utilization in-patient care more than out-patient is the motivation to become PhilHealth member

4 Primary Care Benefit 1 (PCB1) Expanded OPB; effective April 1, 2012 Sponsored Program, Overseas Workers Program, Organized Group members and dependents Aims to: Expand the number of services Increase the utilization rate for PCB services Enhance the incentives for PCB providers Ensure complete and timely reporting

5 Primary Preventive Servicesdetermined by the doctor based on patient s health need Consultation the first consultation visit in a given year shall at least include taking or updating individual health profile Visual inspection with acetic acid Regular BP measurements Breastfeeding program education Periodic clinical breast examinations Counselling for lifestyle modification Counselling for smoking cessation Body measurements Digital Rectal Examination

6 Diagnostic Examinations Complete Blood Count (CBC) Urinalysis Fecalysis Sputum microscopy Fasting Blood Sugar Lipid profile Chest x-ray

7 Drugs and Medicines Asthma including nebulisation services Acute Gastroenteritis (AGE) with no or mild dehydration Upper Respiratory Tract Infection (URTI)/Pneumonia (minimal and low risk) Urinary Tract Infection (UTI)

8 Obligated Services BENEFITS/SERVICES TARGET CLIENTS FREQUENCY BP measurement Non-hypertensive (18 years old and above) Once a year Hypertensive (with BP >/= 140/90 mmhg Once a month Periodic clinical breast examination Female, 25 years old and above Once a year Visual inspection with acetic acid Female, years old with intact uterus Once a year

9 What to do as PCB Provider Enlist entitled members (SP, OP, OWP) Do/update individual health profile of enlisted members Provide services identified in PCB1 as needed by the members and qualified dependents Perform obligated services

10 Objectives Assess the implementation of PCB1 Specifically, 1. Describe the process of implementation 2. Present the initial results of PCB1 utilization 3. Highlight the PCB providers (and LGUs) response to this benefit package

11 Methodology 1. Analysis of PhilHealth and LGU reports 2. Key informant interview 3. Observation from PhilHealth events (e.g. PhilHealth MOVES)

12 DOH Department Memorandum No Assignment of Sponsored Program Members identified through NHTS-PR to their Primary Care Providers

13 Where should entitled members go: Assignment of PCB1-entitled members Rural Health Unit Health Center OPD 1 of hospitals NHTS-NG a a SP-municipality/city a a SP-Gov b b a SP- Congress c c c SP-others c c c Organized Groups b b a OFWs b b a a - primary assigned PCB provider b - alternative PCB provider if (*) is inaccessible to PCB1 covered members c-- can be assigned in any PCB provider 1 - Out-Patient department of government hospitals (LGUs and national hospitals)

14 Accredited facilities providing PCB1 have increased RHU RHU 2012 Hospital 2010 Hospital 2012

15 ...And 16% more LGUs are participating as PCB1 providers BEFORE (as of December 31, 2010) LGUs with LGUs without NOW (as of October 2012) LGUs with LGUs without Primary Care Benefit (Out Patient Benefit) Provider LGUs= 1628

16 Assigning NHTS-SP in PCB Providers 500, , , , , , , , ,000 50,000 - PhP 1.1 B Per Family Payment Rate paid to PCB Providers as of October 2012

17 % of assigned SP members have enlisted Total Assigned SP Enlisted SP

18 Feedback from the field In Cebu, MHOs are going out to barangays to do health profile increased case finding In Caraga, SP members says they can see their health care provider even when they are not sick In Cagayan Valley, LGUs are hiring additional human resources to do individual health profiling

19 In summary... In the past 6 months, PCB providers have increased Sponsored Program members have been assigned to PCB providers SP members have been informed of their benefits and their access to health services have been improved LGUs are strengthening their role as health care providers

20 With PCB1... Filipinos have entry to better health Bawat Pilipino Myembro Bawat Myembro, Protektado Kalusugan natin, Segurado!